Adopting Metacognitive Interpersonal Therapy to Treat Narcissistic Personality Disorder with Somatization

Narcissistic personality disorder (NPD) is characterized by an intellectualizing narrative style, poor metacognition, maladaptive interpersonal schemas, a restricted set of states of mind, impaired agency and perfectionism. Metacognitive Interpersonal therapy targets these dysfunctions with a series of formalized procedures aimed at first forming a shared formulation of functioning which patients and therapists can then use to plan change. We describe here the core NPD pathology and illustrate the therapy process of a patient with NPD and a somatization disorder. Implications for treatment of NPD are discussed together with a call for empirical testing of therapies for this severe condition.     

Disorganization and Individual Psychotherapy for Schizophrenia: A Case Report of Metacognitive Reflection and Insight Therapy

Despite being a characteristic symptom of schizophrenia, implications for therapy with persons experiencing prominent disorganization have received less attention in the psychotherapy literature than have other aspects of the disorder. As such, formal thought disorder may be viewed largely as a barrier to effective participation in therapy. In contrast, though, a range of writers from varied traditions have stressed that this feature of schizophrenia is meaningful and improved coherence of speech is an important and viable component of treatment and recovery. This paper suggests that an emergent integrative psychotherapy, metacognitive reflection and insight therapy (MERIT), may be well-suited for work with persons experiencing disorganization symptoms. A brief overview of MERIT is provided, followed by a case report of an 18-month course of therapy with a man with severely disorganized speech.     

The Application of Cognitive Therapy for Command Hallucinations

It has become increasingly recognized that cognitive therapy (CT) is an effective treatment for the positive symptoms of schizophrenia yet there are few cognitive therapists in North America who are specialized to work with this patient population. There is a need for further dissemination of CT for schizophrenia in order to increase its availability. A first step in dissemination is to become familiar with the cognitive theory and therapy model, as applied to schizophrenia. The purpose of the present paper is to demonstrate the applicability of CT for psychosis, using the example of command hallucinations. First, we summarize the cognitive theory of command hallucinations and present the stages of CT, using the example of “Joe,” a 24-year-old male with schizophrenia. The paper concludes with practical suggestions of how to enhance the effectiveness of CT for command hallucinations.     

Cognitive Therapy for Command Hallucinations: Not a Quasi-Neuroleptic

Command hallucinations (CH) are a distressing and high-risk group of symptoms that have long been recognised but little understood, with few effective treatments. In this paper we report and discuss the efficacy of cognitive therapy (CT) modified in accordance with ‘social rank theory,’ in a single blind randomised controlled trial. 38 patients with command hallucinations were randomly allocated to CT or treatment as usual and followed up for 6 then 12 months. Large reductions in compliance behaviour were obtained (effect size = 0.97) favouring the CT group. Other significant differences were found and maintained at 6 months follow up.     

Electrophysiologic Manifestations of Impaired Temporal Lobe Auditory Processing in Verbal Auditory Agnosia

The present study examined the extent to which verbal auditory agnosia (VAA) is primarily a phonemic decoding disorder, as contrasted to a more global defect in acoustic processing. Subjects were six young adults who presented with VAA in childhood and who, at the time of testing, showed varying degrees of residual auditory discrimination impairment. They were compared to a group of young adults with normal language development matched for age and gender. Cortical event-related potentials (ERPs) were recorded to tones and to consonant-vowel stimuli presented in an "oddball" discrimination paradigm. In addition to cortical ERPs, auditory brainstem responses (ABRs) and middle latency responses (MLRs) were recorded. Cognitive and language assessments were obtained for the VAA subjects. ABRs and MLRs were normal. In comparison with the control group, the cortical ERPs of the VAA subjects showed a delay in the N1 component recorded over lateral temporal cortex both to tones and to speech sounds, despite an N1 of normal latency overlying the frontocentral region of the scalp. These electrophysiologic findings indicate a slowing of processing of both speech and nonspeech auditory stimuli and suggest that the locus of this abnormality is within the secondary auditory cortex in the lateral surface of the temporal lobes.     

Metacognitive Interpersonal Therapy Improves Adherence to Antiretroviral Therapies in a Man with a Severe Personality Disorder: A Case Report

Treatment adherence by patients with HIV ensures they gain the full benefit of antiretroviral medications and extend their lives. One problem which may contribute to poor adherence is deficits in metacognition or the capacity to make sense of mental states. In particular, persons who struggle to notice and think about their thoughts and feelings may be less able to direct their own recovery by taking advantage of effective treatments. This raises the possibility that treatments which lead to improved metacognitive function may enhance treatment adherence. We describe the case of a man in an advanced stage of AIDS with Kaposi’s sarcoma. The patient was treated with Metacognitive Interpersonal Therapy combined with psychoeducation about pharmacological treatment for HIV. Primary medical outcomes were suppression of viral load, increase of CD4 count and control of AIDS related conditions such as Kaposi’s sarcoma. The primary psychological outcome was reduction of personality disorders criteria. The patient was able to understand what led him to discontinue medication and then later regain full adherence. He achieved suppression of viral load and restore of CD4 count. As regard severity of personality disorder, he achieved reliable change. Interventions such as Metacognitive Interpersonal Therapy may assist patients with HIV to gain the metacognitive capacities to make sense of their medical and psychological challenges and adhere to antiretroviral therapies leading to enhanced levels of health. Future studies are needed to explore these findings in larger controlled studies.     

Metacognitive Reflective and Insight Therapy for a Person Who Gained Maximal Levels of Metacognitive Capacity and Was Able to Terminate Therapy

Schizophrenia often involves a loss of metacognitive capacity, or the ability to form a complex and integrated sense of self and others. Independent of symptoms and impairments in neurocognition, metacognitive deficits are a barrier to the formation and sustenance of goal-directed activities of daily life and ultimately to recovery. Metacognitive reflective and insight therapy (MERIT) is a form of psychotherapy intended to assist patients to recover metacognitive capacity through intensive individual therapy. This paper presents a case illustration of how MERIT assisted a patient with prolonged schizophrenia and significant metacognitive deficits to develop a robustly complex understanding of himself and others and then to use that knowledge to agentically monitor his own experiences and effectively respond to life challenges. The eight elements of MERIT that stimulate and promote metacognitive capacity are presented with an emphasis on how they were implemented when the patient had reached some of the higher levels of metacognitive function.     

Dialectical Behavior Therapy for Managing Interpersonal Relationships

Dialectical Behavior Therapy (DBT) is a treatment designed for individuals having borderline personality disorder (BPD), patients having binge eating disorder, co-morbid substance dependence and BPD, and depressed older adults. This paper aims to explore the use of DBT and to ascertain the status of DBT education in treating difficulties in handling interpersonal relationships among clients seeking counseling and psychotherapy. The skills training mode can be employed for teaching skills to solve relationship problems. Validation and acceptance strategies can lessen rejection sensitivity and negative feelings that make interpersonal situations chaotic. Black and white thinking can be resolved by finding a middle path through acceptance and change. This paper suggests the possible utility of DBT for enhancing psychological well-being in clients.     

Metacognitive Therapy Focused on Psychosocial Function in Psychosis

Metacognitive Insight and Reflection Therapy is a manual-based individual psychotherapy aimed at enhancing four metacognitive processes through patient’s personal narratives which may promote recovery by helping individuals suffering from schizophrenia to develop a richer and more integrated sense of self. This study is a single case analysis of the effects of a meta-cognitively oriented CBT on residual psychotic symptoms and functional targets. Outcome measures (PANNS, PDI 21, BAVQ-R, PSP, MAS-A) were collected at two different times: pre-CBT and 1-year. Results showed reductions in the distress, preoccupation and conviction associated with delusions and improvements in metacognitive abilities, social functioning, hopefulness and of the sense of self-confidence to cope with the psychotic symptoms. Adopting a metacognitive perspective during psychotherapy had several benefits: to foster the development of therapeutic alliance, to allow the patient to assess the efficacy and acknowledge the consequences of the different strategies he could use to cope with his symptoms and to question the predominance of his delusions in his life. To conclude, Metacognitive Reflection and Insight Therapy seem particularly adapted to address psychosocial issues, such as social or work functioning.     

The Mutual Development of Intersubjectivity and Metacognitive Capacity in the Psychotherapy for Persons with Schizophrenia

While cognitive behavioral approaches have been shown to help some individuals with schizophrenia, these approaches may be limited when working with patients with impairments in the metacognitive abilities required to form complex and integrated representations of themselves and others. In response, this paper explores the possibility that a key to working with patients with relatively impaired self-reflectivity lies in explicitly focusing on a patient’s intersubjective experience within psychotherapy. We offer theoretical and empirical support for the assertion that the tolerance and capacity for intersubjectivity is a basis for the development of self-reflectivity in general. We also explore how the fostering of intersubjective processes in psychotherapy might enable some patients to form more complex ideas about themselves and so better ward off delusions in the face of the challenges of daily life. To illustrate these principles we present the case of a patient with tenaciously held delusions and limited capacity for self-reflection. We discuss when and how the therapist’s awareness and verbalization of intersubjective processes within session allowed her and the patient to develop more complex and consensually valid ideas about him as a being in the world, which then assisted the patient to achieve improvements in a number of domains in his life.     

Verbal Participation and Improvement in Group Therapy

The challenge of group treatment with ego impaired children is to provide a situation in which their maladaptive efforts to organize volatile affects and impulses can be tolerated and structured. This article addresses the process of culture building in group and how it can provide a cohesive structure for affective expression that is acceptable and tolerable to the defensive, resistant child. In particular, the author will argue that it is through the sense of normality and commonality engendered by indigenous peer culture that the members initially develop a structure and language for affiliation, play, and mutual identification. By facilitating the cohesion of indigenous peer culture, the therapist creates a sufficient holding environment to begin a dialogue involving both verbal and nonverbal communication. For children who are difficult to engage in discussion, let alone treatment, this dialogue is the essential process for creating a corrective emotional experience. Through a concise case study, the author describes the process by which the children's efforts to express and create their own culture are cultivated, managed, and understood.     

Australian Norms and Retest Data for the Rey Auditory and Verbal Learning Test

This article presents normative data for the Rey Auditory and Verbal Learning Test (RAVLT). A representative sample of 390 healthy young adults aged between 18 and 34 living within the Sydney metropolitan area, Australia, completed Form AB of the RAVLT as part of the Macquarie University Neurological Normative Study. Retest data were collected from a subsample of 98 participants after an interval of 1 year. Norms were derived for commonly used measures of the RAVLT and are presented for the whole sample as well as separately for males and females with different levels of education. Age was not found to impact significantly on test performance for this group of young adults, and therefore age‐adjusted norms are not provided. An excel program to calculate RAVLT standard scores (mean of 10 and standard deviation of 3) can be downloaded from http://www.psy.mq.edu.au/RAVLT . Poor test–retest reliability raises concerns about the use of the RAVLT in clinical diagnosis.     

Verbal Fluency,Semantics, Context and Symptom Complexes in Schizophrenia

Lexical-semantic access and retrieval was examined in 15 adults diagnosed with schizophrenia and matched controls. This study extends the literature through the inclusion of multiple examinations of lexical-semantic production within the same patient group and through correlating performance on these tasks with various positive and negative clinical symptoms. On tasks of verbal fluency, meaning generation, sentence production using contextual information and confrontation naming, participants with schizophrenia made significantly more semantic errors on naming tasks; produced fewer meanings for homophones; produced fewer items on semantic, phonological, cued and switching fluency tasks; and produced more errors on sentence production tasks when compared to healthy controls. Significant correlations were also observed between ratings of psychomotor poverty and measures of semantic production and mental inflexibility. This study has provided additional evidence for deficits in lexical-semantic retrieval which are not due to underlying semantic store degradation, do not involve phonological based retrieval, and at the level of sentence generation appear to vary as a function of the contextual constraints provided.     

Occupational Therapy in the Treatment of Schizophrenia

A review of Occupational Therapy literature on the treatment of schizophrenia identified four loosely defined treatment categories: (1) sensory integration, (2) activity groups, (3) social skills training, and (4) living skills training. From available data is appears that sensory integration therapy has been able to improve the motivation and affect of schizophrenic patients and structured activity programs can contribute to a reduction in positive symptomatology. Social and living skills training show promise as treatment methods to promote the community functioning of this population. A future need to establish which schizophrenic patients and what schizophrenic symptomatology respond to different types of treatment is identified.     

Critical Issues in Using Homework Assignments Within Cognitive-Behavioral Therapy for Schizophrenia

Presents an overview of the research findings to date and practical guidelines for the use of homework in cognitive-behavioral therapy for schizophrenia. In particular, the article outlines strategies to combat the common difficulties experienced when using homework with clients with schizophrenia and the types of homework assignments that may be most helpful. The empirical evidence suggests that cognitive-behavioral therapy incorporating homework assignments help clients to improve at least 60% more than those in treatment without homework. Despite that most therapy formulations incorporate homework as an integral component of treatment for schizophrenia, prior research has identified that practitioners consider homework to be less helpful for clients with delusions and hallucinations. Interventions to enhance homework compliance in the treatment of clients with schizophrenia are outlined.     

The Effects on Interpersonal Verbal Behaviour of Varying Participant Role in Initial Dyadic Conversations

Abstract

Approaches to social skills assessment and training have generally failed to view behaviour in context or consider the contingencies of particular acts. The Verbal Interaction Analysis System (VIAS) measures the frequency of particular sequences of verbal behaviour that feature in the speech of both participants in a dyadic exchange. Data are presented to illustrate the use of the VIAS and demonstrate that it is responsive to manipulated changes of role by participants. In addition they support the initial assumptions of the VIAS whereby active contributors to the maintenance of a conversation are judged as more competent. In particular, independent ratings of global interpersonal behaviour were negatively correlated with verbal behaviour that discouraged topic maintenance. These findings are interpreted as supporting the hypothesis that competence in interpersonal interactions is substantially determined by the effects that one participant's verbal utterances have on those of the other participant and vice versa. Furthermore, support is also given to the view that it is unproductive to consider the verbal behaviour of one person outside the context of the interaction with the other person in a dyadic exchange. Discussion is mainly concerned with the need to adapt assessment measures and training procedures to take account of the current findings.     

Interpersonal Problems,Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder

Objective: To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up. Method: Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up. Results: Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity. Conclusions: Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population.     

Metacognitive Therapy in Major Depression: An Open Trial of Comorbid Cases

This open trial investigated the transdiagnostic effects of metacognitive therapy (MCT) in patients with severe major depressive disorder and comorbid psychiatric disorder. Ten patients were treated with MCT over 10 sessions and were assessed with measures of depression, anxiety, rumination, and metacognitions at pre- and posttreatment and at 6 months follow-up. None of the patients were diagnosed as depressed at posttreatment, and of the initial 21 total diagnoses at pretreatment only 3 diagnoses remained at postintervention. The effect sizes were large for symptoms of depression, rumination, and worry. At 6 months follow-up standardized recovery criteria on the BDI showed that 70% were recovered, 20% improved, and 10% unchanged. The results indicate that MCT was associated with high rates of transdiagnostic improvement.